20141173 Ver 1_Shoreline Stabilization_20141103

State of North Carolina
W. R 2 0 1 4 1 1 7 3Department of Environment and Natural Resources
Division of Water Resources
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,,e ' 15A NCAC 02H 0500 - Water Quality Certification, Shoreline Stabilization
Division of Water Resources
FORM SSGP 10 -2013
Shoreline Stabilization Application Form
Four copies of the application (including attachme ) arhdNh�'application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit 0 `�
1650 Mail Service Center D
Raleigh, NC 27699 -1650 NOV I 0 2014 1 J
I. Applicant Information [15A NCAC 02H 0502(a)]
1 Owner triormation
Name C-Kk
Mailing Address
Telephone Number� �b ��`��Fax Number
E -mail Address �`�`npr �� �`\�� •�-�m
2 Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here
http / /www saw usace army mil/ Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM pd f) must be attached if the Agent has signed this application form
Name Y?4.",)(' 4"'__
Company Affiliation
Mailing Address
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f},fsers�l�� ✓QC_ ZS-'& 7,S-'
Telephone Number 7Uf{ —CGS- 371.3 Fax Number
E -mail Address ('cr►dy (� /cc D� tS,� %1•��.sM
Person to receive the Certification Approval
II. Project Information [15A NCAC 02H 0502(a) & (b)]
1 Attach a vicinity map (i a street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads
2 Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM SSGP 10 -2013
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Page 1 of 4

etc ), rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations,
and construction access corridors You may use the diagram provided at the end of this
application form
3 Attach a photograph of the shoreline/ buffer proposed to be stabilized (Include a scale
of some sort- a yard stick, shovel handle, etc )
4 Location of the property (where work is to be conducted)
County. Nearest Town
Subdivision name or site address (include phase /lot number)
Poe,, -t � : - L T /.2-t
Directions to site - please include road names and numbers, landmarks, etc
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5 Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc ) UA6e-vim(' Pt3
6 Property size (acres)
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7 Lake/ river/ ocean adjacent to property L9 eNe-
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary) i's en o c-d�s
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9 Will work be conducted from land? From water? ❑
10 Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc )
below the normal pool lake level/ Normal Water Level in square feet or acres
11 Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc ) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres 7 GO 51. fl. L I a y bav( _ FA-A K-
12 Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance).
�l'ZL� � t,sSS'j'L.� �� �`�d�tiw- �.'���, �inc� � 1C✓'��. 1'.S� �f 01i5�LTET l✓`�7J
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Owner /Agent's Signature* [1 A NCAC 02H 0502(f)l Date
Agent's signature is valid only if an authorization letter from the owner is provided
FORM SSGP 10 -2013 Page 2 of 3

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124 P 01�
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La ke
(At Full Pond/ Normal Water Level)
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft) *:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10 -2013 Page 3 of 3
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Q 4409 Stoney Pointe Ct
Belmont, NC 28012
These directions are for planning purposes only. You may find that construction
projects, traffic, weather, or other events may cause conditions to differ from the map
results, and you should plan your route accordingly. You must obey all signs or
notices regarding your route.
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